Averil Hart was badly failed by every NHS service that was meant to be caring for her, the investigation concluded.
Photograph: Handout

A talented young student died of anorexia because of numerous “clear failures of care” by GPs, hospitals and specialists in eating disorders, a scathing report by the NHS ombudsman has concluded.

Averil Hart’s death in December 2012 at the age of 19 “was an avoidable tragedy” caused by an array of health professionals failing to appreciate how dangerously unwell she was, the ombudsman said in a report released on Friday.

While her family and even her cleaner could see that she was losing weight after she moved to Norwich to study, her GP surgery and psychologist in charge of her care did not, her father, Nicholas, told the Guardian.

In one of the most trenchant criticisms of NHS care in years, Rob Behrens, the parliamentary and health service ombudsman, warned that the errors which culminated in Hart’s death illustrated “widespread problems with eating disorders services in the NHS”. Other people with potentially fatal conditions involving food have also died because of poor care, he said.

“Our investigation found that Averil’s tragic death would have been avoided if the NHS had cared for her appropriately. Several NHS organisations missed opportunities to prevent the deterioration which led to her final admission to the hospital where she died,” the ombudsman’s wide-ranging report said.

Hart was first diagnosed with anorexia at 17 when she was doing her A-levels. She spent almost a year as an inpatient at a specialist eating disorders unit in Cambridge in 2011-12 but was discharged in August 2012 so she could start studying English and creative writing at the University of East Anglia (UEA) a month later.

The medical documentation that accompanied her discharge was clear that she was “vulnerable to subsequent relapse”. Doctors stressed that she needed ongoing monitoring and support to help her negotiate three potentially stressful events: leaving home, starting at university and coming under the care of a different NHS eating disorders service.

However, “there were multiple opportunities between August and December 2012 to identify what was happening to Averil, to intervene to remedy the situation at that time, and therefore to prevent the subsequent course of events that led to the final emergency admission to hospital which culminated in her death”.

Hart was badly failed by every NHS service that was meant to be caring for her from August 2012, Kirkup found. The care plan drawn up on her discharge by the eating disorders service in Cambridge was inadequate because it did not highlight the urgency of invoking a contingency plan if she deteriorated. Her weight and mental health were not monitored properly before she moved to Norwich.

Once there, the Norwich eating disorders service, which took over her care in September 2012, did not appoint a care coordinator to oversee her treatment for a month, which meant she did not receive adequate assessment or support during that time. She had lost 6kgs by the time she was finally weighed.

Although she was meant to be seen weekly by the GP surgery at the UEA, that only happened three times and at the last appointment – on 8 November – “a locum GP told her she did not need to come back for a month”.

When her father and older sister, Imogen, visited her on 28 November “they were shocked by how much weight she appeared to have lost”. They sought help for her as an emergency. But she was found collapsed in her room in university accommodation on 7 December. She had suffered severe brain damage caused by her extremely low blood glucose and died eight days later in hospital.

On 8 November a locum GP told Averil Hart she did not need to return to the surgery for a month. On 7 December she collapsed and died in hospital days later. Photograph: Handout

“There were multiple serious departures from the standards of care expected that meant that the critical nature of Averil’s condition was not recognised and treatment was not implemented properly as it could and should have been,” the report added.

The failings by the UEA GP practice, and the acute NHS trusts in Norwich and Cambridge which provided treatment, as well as the Norwich eating disorders service, were so serious that each was guilty of “service failure”, said Behrens. The ombudsman’s office investigated the case after previous inquiries by the NHS bodies involved in Hart’s care proved so inadequate they constituted “maladministration”, he added.

Hart’s father said: “Averil’s death wasn’t a one-off. Other people with anorexia have died needlessly because the lessons from her death weren’t learned quickly enough.

“Averil was a great creative writer and the perfect daughter: full of fun, really cheeky, and was often a bit mischievous but got amazing grades.”

Andrew Radford, the chief executive of Beat, an eating disorders charity, said: “This tragedy demonstrates, once again, the devastation eating disorders can cause. The Hart family have not only had to grieve for their daughter but also had to face the fact that her death could and should have been prevented.”

NHS England said that eating disorders services had been expanded and that eight out of 10 young people suffering from one was now treated within four weeks thanks to a £150m investment.